1. SEX ADDICTION 101: SCREENING AND TREATMENT
Christina Schmolke, R. Psych
Certified Sex Addiction Therapist Candidate, International Institute for Trauma and Addiction Professionals

2. Objectives
Overview
Screening
Resources

3. What is Sex Addiction?
Found in DSM IV under Sexual Disorder, Not Otherwise Specified (American Psychiatric Association, 2001)
Distress about a pattern of repeated sexual relationships where the individual is objectified
Controversial sexologist John Money later popularized the term as a nonpejorative designation for unusual sexual interests.3456 He described paraphilia as "a sexuoerotic embellishment of, or alternative to the official, ideological norm."7
Paraphilias: Exhibitionism, Voyeurism, Frotteurism

4. What is Sex Addiction?
Sexual addiction is defined as any sexually-related, compulsive behavior which interferes with normal living and causes severe stress on family, friends, loved ones, and one's work environment (sexhelp.com)

5. What is Sex Addiction?
“An attempt to secure attachment without risking emotional vulnerability” (Adams, personal communication, January 28, 2011)
Courtship disorder
Linked to fear of rejection
Attachment perspective – disrupted attachment – have difficulty trusting in others and establishing intimacy. Sex is a way to survive or cope with crisis; numb pain; nurture oneself and restore damage.

6. Prevalence
3-10% of the general population (Carnes, 1992; Lanngstrom & Hanson, 2006)
Past: 75% male, 25% female
Now: Women equally as likely to access inpatient resources as men (Carnes, 2006)
40% of people with severe cybersex addiction are women (Cooper et al., 2000)
From: Hypersexual Disorder: A Proposed Diagnosis for DSM-V
Martin P. Kafka
La°ngstro¨mand Hanson (2006), in a population-based epidemiological
study,definedhighratesofenactedsexualbehavior
in a large Swedish community sample (n=2450 men and
women). They provided an operational definition for ‘‘impersonal
sex’’ that included six specific enacted behaviors (frequency
ofmasturbation/month, frequency of pornography use/
year, number of sexual partners in past year and per active year,
having extra-partnered sexwhile in a stable partnered relationship,
and ever participating in group sex) and one attitudinal
factor (preferring a casual sexual lifestyle). They utilized a
composite of thesemeasures to identify‘‘hypersexuality’’as an
indicator for themost sexually active5–10%of their sample. In
the group of bothmen andwomenwho were rated as‘‘high’’on
indicators of hypersexuality, correlations among such sexual
behaviors were statistically significant.

7. Associated Factors (Carnes, 1992)
Rigid (77%) and disengaged (87%) family background
Emotional abuse (97%)
Sexual abuse (83%)
Physical abuse (71%)
Addicts who have molested children had been the most severely emotionally abused as children.

8. Sex Addiction and Substances
Genetic Factors
Co-morbid substance Abuse (42%)
Cocaine use (50-70%; Washton, 1989)
Domapine strands tend to be shorter for those who have addictions, eating disorders, ADHD, Tourette’s. Insufficiency of dopamine may put people at risk for addiction.
-Linking to nomadic people and novelty seeking – more is better
Severity of abuse predicted the number of co-occuring addictions
Stimulants – unrecognized cause of relapse

9. Types of Addiction Substances Feelings Compulsive Attachments Alcohol
Process
Sex
Work
Exercise
Food
Money
Substances
Alcohol
Cocaine
Methamphetamine
Marijuana
Feelings
Rage
Fear
Love
Self-loathing
Compulsive Attachments
Rescuing
Co-dependence
Traumatic bonding

10. Levels of Behaviours Level 1: Culturally accepted behaviours
Masturbation
Compulsive Relationships
Pornography (cybersex)
Anonymous sex
Prostitution
Risk of escalation
Rationalization can fuel behaviour 10

11. Levels of Behaviours Level 2: Clear violation of cultural norms
Exhibitionism
Voyeurism
Indecent phone calls or liberties

12. Levels of Behaviour Level 3: Profound Boundary Violations
Child molestation
Incest
Sexual assault (rape and violence)
-Common for people to escalate
-Most people stay at 1 and 2 levels
-Offending is different from addiction
-Help us organize the addictive behaviour
-Some offenders may consciously inflict pain or act out rage
-Addicted sex offenders use others for sexual gratification
-About 20% of sex addicts actually engage in offending behaviour - 12

13. Criteria for Sex Addiction (Carnes, 2010)
1. Recurrent failure to resist impulses to engage in specific sexual behaviour
2. Frequent engaging in those behaviours to a greater extent or over a longer period of time than intended
3. Repeated unsuccessful efforts to control, cut back on, or to stop
Cravings – difficult to control
Cybersex – on the weekends, week nights
Promises
Research shows that at least 3 criteria need to be met in order for it to be considered an addiction
After education on sex addiction, many clients are able to identify at least 5-7 13

14. Criteria for Sex Addiction
4. Inordinate amount of time spent in obtaining sex, being sexual, or recovering from sexual experience
5. Preoccupation with the behaviour or preparatory activities
6. Frequent engaging in the behaviour when expected to fulfill other obligations
4. Loss of time grieved
5. Preoccupation – always on their mind
6. Other parts of their life begin to suffer

15. Criteria for Sex Addiction
7. Continuation of the behaviour despite negative consequences
8. The need to increase the frequency and intensity of behaviour to achieve the desired effect
9. Giving up or limiting social, occupational, or recreational activities because of the behaviour
10. Distress, anxiety, restlessness, or irritability after engaging in the behaviour
7. Criteria for addiction
8. Tolerance – escalation of the behaviours to achieve desired effect. Pornography – different situations. Going outside the home.
9. Limiting social activity – difficult to make plans, commitments
10. High levels of hopelessness, despair

16. Adverse Consequences (Carnes, 1992)
Loss of a partner (40%)
Severe marital conflict (70%)
Suicidal obsession (72%)
Suicide attempts (17%)
Exposure to STIs (68%)
Legal risks (58%)
Financial consequences (58%)

17. Contributing Factors Genetic factors Family dysfunction (child abuse)
Inability to sustain intimacy
Emotion Management
Addiction migration
Genetic factors: runs in families, processing issue with serotonin, dopamine, etc Increased vulnerability
Genetic predisposition – we have an inherited genetic structure.
Neurochemical vulnerability – neurochemical deficits are created
Neurochemical change – prolonged use of excessive highs alter neurochemical balance
Neurochemical imbalance – addiction services to preserve imbalance to the person feels normal
Family – other members with addictions, modeling, child abuse.
-Addiction can be a failure to bond. Children busy themselves. Inability to sustain attachment. Trust.
Child abuse is common, leading to extreme reactivity or hypersensitivity when a child is upset. Evidence to support that abuse alters the development of the brain. Age of onset of abuse influences how the brain is impacted. Early stress programs our stress hormone to have a more pronounced and exaggerated response to subsequent stressors 50% are at risk of addiction.
-Fear alters the structure of the brain. Take fear away, and the child will feel like something is missing and create chaos if this is pronlonged. Cortisol and norepinephrine.
Intimacy – fundamental failure to trust others and to bond with them. Learn to become independent and want to have control.
Emotion management – children learn from parents how to access and deal with emotions. The child borrows the frontal lobes of the parent. Families where parents do not tolerate feelings lead to children who may avoid.
Addiction migration – Milkman and Sunderwirth – Craving for Ecstacy – basic types of addiction
Arousal addictions – compulsive gambling, stimulant use, high risk, sex
Satiation – compulsive overeating, alcohol, depressant drugs
Fantasy addiction – psychedelics, marijuana, mystical preoccupation
p. 128 – Don’t call it love – Maxine

18. Sexual Anorexia (Carnes, 1997)
Extreme aversion to, or avoidance of, anything sexual in nature
Loss of appetite for sexual interactions
Preoccupation with others’ sexuality
Sex is my most terrifying need
Fear of rejection
Distortions about body appearance
Do you dread and fear sexual contact?
Do you avoid anything connected with sex?
Are you disgusted with your personal appearance and bodily functions?
Do you engage in self-destructive behaviour to limit, stop, or avoid sex?
Do you struggle with sexual desire

19. Patterns of Behaviour: The 10 Types
1. Fantasy Sex
2. Voyeurism
3. Exhibitionism
4.Seductive Role Sex
5.Trading Sex
From followed over 1000 sex addicts. Categorized behaviour into types.
Fantasy sex: Sexually charged fantasies, relationships, and situations.
Arousal depends on sexual possibility
Cannot move beyond desire
Fear of rejection
E.g., spending inordinate amounts of time thinking about the future and the past, creating sexualized or seductive atmospheres that you prefer not to act on, spending a large time of preparing for a sexual episode
Voyeurism: Non-participants in sex game. Visual stimulus is arousing
Move beyond fantasy to seek out objects in the real world
Objectification – will go into a trance
E.g., pornography, adults bookstores, peep shows, using binoculars to look into windows, sexualizing others in public places, sexualizing materials not sexually explicit
Exhibitionism – attracting attention to body or parts of body. Arousal from reaction of viewer.
Attracting attention to body or sexual parts of the body.
Sexual arousal stems from reaction of viewer whether shock or interest.
E.g., exposing yourself in a public place, being sexual or undressing yourself in public, using choice clothing to expose yourself, belonging to a nudist club
Seductive role sex
Seduction of partners. Relationships about power and conquest. Act differently with different people. Flirtation and romance
Arousal is based on conquest and diminishes rapidly after initial contact.
May have many different partners at the same time
E.g., using seduction to gain power, hustling at health clubs, bars, failing to make commitments in order to be available for sex
Trading Sex
Selling or bartering sex for power.
Arousal is based on gaining control of others by using sex as leverage
Replication of childhood sexual abuse where child gained power in a risky game of being sexual with the caregiver
E.g., making sexually explicit photographs or videos, having pornography collections, pimping others, receiving money or drugs for sexual activity

20. Patterns of Behaviour: The 10 Types
6. Intrusive Sex
7. Paying for Sex
8. Anonymous Sex
9. Pain Exchange Sex
10. Exploitive Sex
Intrusive Sex
Boundary violation without discovery. Touching in crowds, lewd jokes,
Sexual arousal occurs by violating boundaries with no repercussions. E.g., doctors, clergy
Intrusion becomes the obsession
E.g., touching or fondling without permission, making inappropriate jokes or sending forwards.
Paying for sex
Purchasing of sexual services. Focused in touching, foreplay, and intimacy without the hassles of a relationship
Arousal is connected to payment for sex, and with time the arousal actually becomes connected to the money itself
Inability to be intimate with partner and communicate needs
E.g., paying for sexually explicit phone calls, using an escort or phone service, paying someone for sexual activity, personal ads, saunas, massage parlours.
Anonymous Sex
High-risk sex with unknown persons.
Arousal involves no seduction or cost and is immediate.
Often followed by sexual anorexia
Early sexual relationships associated with fear become re-enacted with others. Cannot be aroused without fear
E.g., Engaging in sex with anonymous partners, cruising beaches, parking lots, rest rooms, having one night stands, participating in group sex.
Pain Exchange
Being humiliated or hurt as part of sexual arousal; or sadistic hurting or degrading another sexually, or both.
Normally a re-enactment of early childhood experience
E.g., receiving physical harm or pain during sexual activity to intensify sexual pleasure, causing harm to partner in order to experience sexual pleasure, willingly give up power or act the victim, use sexual aids to enhance experience
Exploitive sex
Exploitation of the vulnerable. Vulnerability is the fuel for arousal
Arousal patterns are based on target “types” of vulnerability.
E.g., forcing sexual activity on a person, including spouse or partner.
Dominic Strauss Khan – head of the International Monetary Fund was singled out as attacking a maid who says that he attacked her. Known as the “great seducer.”

21. Child Pornography
Canadian law forbids the use of production, distribution, and possession of child pornography
Streaming child pornography
Have any of your sexual activities involved minors?
Child pornography – under the age of 18 depicted or engaged in sexual activity
-Can be sentenced to up to five years in prison – some of the toughest penalties in the world
-2002 cyberluring is banned, using the internet to communicate with children regarding sex 21

22. Age of Consent
In 2008, the Tackling Violent Crime Act took effect and raised the age of consent from 14 to 16 in Canada. Exceptions for this act are that a youth of 12 or 13 can consent to activity if his/her partner is less than two years older than them. A 14 or 15- year-old youth can consent to sexual activity with a partner who is less than five years older then them.
-Laws criminal and uniform across Canada
Position of trust under 18 – Section 153 then goes on to prohibit the sexual touching of a person under 18 by a person in three circumstances: if he or she is in a "position of trust or authority" towards the youth, if the youth is in a "relationship of dependency" with him or her, or if the relationship is "exploitative". The term "position of trust or authority" is not defined in the Code but the courts have ruled that parents, teachers, and medical professionals hold a position of trust or authority towards youth they care for or teach. For determining whether or not a relationship is "exploitative", s. 153 (1.2) of the Code provides that a judge can consider how old the youth is, the difference in ages between the partners, how the relationship evolved, and the degree of control or influence that the older partner has over the youth. 22

23. Core Beliefs I am basically a bad, unworthy person
No one would love me as I am
My needs are never going to be met if I have to depend on others
Sex is my most important need
Perception – I am not attractive, and other women/men are more attractive than me
I am incapable of having a real relationship. I will have to convince a person to be with me
My needs can only be met by luck or chance, careful strategizing, or the accumulation of money and power
I need sex all the time and I cannot get enough. I am the only one that needs sex this much

24. The Addictive Cycle Belief System Unmanageability Impaired Thinking
Preoccupation
Models are vehicles for how me make decisions, interpret actions, pattern our relationships
Each person has a belief system that has been influenced by assumptions, judgments, and myths that he or she holds to be true. It contains messages from the family about that person’s worth.
Impaired thinking: With the stress I’m under, I deserve it. If I don’t have sex every few days, the pressure builds up. My husband is not sensitive to my needs. Rationalization!
Guilt
Shame
Despair
Ritualization
Compulsive Behavior
© 2008

25. Online Tests Sexual Addiction Screening Test (SAST)*
Sexual Addiction Risk Assessment Test (SARA)
Internet Sex Screening Test (ISST)*
Betrayal Bond Test*
SAST – 45 Y/N questions; helps determine if further ax is needed
SARA – 25 minute test; $30, 23 page print out helps people determine course of action
Internet Sex Screening Test – assess your online sexual behaviour
Betrayal bond – a test which uses a series of statements which describe traumatic bonding.

26. Assessment Sexual Dependency Inventory, Revised (SDI-R) 240 behaviours
Past versus current behaviours
Administered by CSATs
First developed in 1983
96.5% accurate in identifying sex addiction
Used to help break through denial
Developed over research on 932 addicts and partners over 7 years
Constellation of behaviours go together
Printout for client and clinician
Alerts to dangerous behaviours – critical items

27. Task-Based Treatment Group Therapy (175 hours) Twelve Step Meeting
Sponsor
Individual Counselling (2-3 years)
Steps One through Nine
Family Recovery
Couples Recovery
Exercise/Nutrition
Groups – reduce shame, connect to others, break through denial
12-step meetings – same
Sponsor – mentorship
Indvidual counselling – long-term process. Dealing with ceasing the behaviours then dealing with the underlying trauma and the core beliefs
1-9 Breaking through denial, understanding addiction, taking inventory of the costs, establishing sobriety
Family recovery – addiction is a family issue – other members at risk

28. Tasks 1–7 Tasks 8–19 Tasks 19–30 1. Break through denial
2. Understand addiction
3. Surrender
4. Limit damage
5. Establish sobriety
6. Physical integrity
Culture of support
Facing the Shadow & Recovery Start Kit
Tasks 8–19
8. Multiple addictions
9. Cycles of abuse
10. Reduce shame
11. Grieve losses
12. Closure to shame
13. Relationship with self
14. Financial viability
15. Meaningful work
16. Lifestyle balance
17. Building support
18. Exercise and nutrition
19. Spiritual life
Recovery Zone: Creating Personal Recovery
Tasks 19–30
19. Spiritual life
20. Resolve conflicts
21. Restore healthy sexuality
22. Family therapy
23. Family relationships
24. Recovery commitment
25. Issues with children
26. Extended family
27. Differentiation
28. Primary relationship
29. Coupleship
30. Primary intimacy
Recovery Zone II: Creating Family Recovery

29. Overview of 12-Step Fellowships
Sexaholics Anonymous (SA)
Most conservative and evangelical
Only acceptable forms of sexuality are married relationships
Lesbians and Gay Males can’t be sexual by their standards

30. Overview of 12-Step Fellowships
Sex Addicts Anonymous (SAA)
Sobriety personally defined using three circle method
Uses Carnes’ materials
Less clear on sexual anorexia

31. Overview of 12-Step Fellowships
Sex and Love Addicts Anonymous (SLAA)
Largest fellowship
First to identify sexual anorexia and the love addict
Women attend more often

32. Screening with PATHOS
Preoccupied - Do you often find yourself preoccupied with sexual thoughts?
Ashamed - Do you hide some of your sexual behavior from others?
Treatment - Have you ever sought therapy for sexual behavior you did not like?
Hurt Others - Has anyone been hurt emotionally because of your sexual behavior?
Out of Control - Do you feel controlled by your sexual desire?
Sad - When you have sex, do you feel depressed afterwards? 

33. Resources
International Institute for Trauma and Addiction Professionals
Canada Alcohol and Drug Rehab

34. International Institute for Trauma & Addiction Professionals (IITAP)
For more on the Certified Sex Addiction Therapist (CSAT) trainings, the task-centered approach to addiction recovery, and assessment testing for sexual, work and financial issues go to: or
or call
(480) 34

35. SexHelp For additional information about
Dr. Patrick Carnes, links to other resources,
current topics in research, and popular literature, go to:
© 2008 35

36. Contact Information
Website: Blog: Phone: